<!DOCTYPE html>
<html>
<head>
<meta charset="UTF-8">
<link rel="stylesheet" type="text/css" media="screen" href="../../css/bootstrap.min.css">
</head>
<body>
<div class="col-xs-12 col-sm-12 col-md-12 col-lg-12">
	<form class="form-horizontal" onsubmit="return false" id="form">
		<fieldset>
			<div class='form-group'>
				<label class='col-md-2 control-label'>fid</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='fid' type='text' name='fid' id='fid' data-bv-notempty='true' data-bv-notempty-message='fid 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>regsterappid</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='regsterappid' type='text' name='regsterappid' id='regsterappid' data-bv-notempty='true' data-bv-notempty-message='regsterappid 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>regsterpayid</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='regsterpayid' type='text' name='regsterpayid' id='regsterpayid' data-bv-notempty='true' data-bv-notempty-message='regsterpayid 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>hisregno</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='hisregno' type='text' name='hisregno' id='hisregno' data-bv-notempty='true' data-bv-notempty-message='hisregno 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>orderno</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='orderno' type='text' name='orderno' id='orderno' data-bv-notempty='true' data-bv-notempty-message='orderno 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>orderdate</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='orderdate' type='text' name='orderdate' id='orderdate' data-bv-notempty='true' data-bv-notempty-message='orderdate 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>totalfee</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='totalfee' type='text' name='totalfee' id='totalfee' data-bv-notempty='true' data-bv-notempty-message='totalfee 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>registerdate</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='registerdate' type='text' name='registerdate' id='registerdate' data-bv-notempty='true' data-bv-notempty-message='registerdate 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>ampm</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='ampm' type='text' name='ampm' id='ampm' data-bv-notempty='true' data-bv-notempty-message='ampm 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>doctorcode</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='doctorcode' type='text' name='doctorcode' id='doctorcode' data-bv-notempty='true' data-bv-notempty-message='doctorcode 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>doctorname</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='doctorname' type='text' name='doctorname' id='doctorname' data-bv-notempty='true' data-bv-notempty-message='doctorname 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>deptcode</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='deptcode' type='text' name='deptcode' id='deptcode' data-bv-notempty='true' data-bv-notempty-message='deptcode 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>deptname</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='deptname' type='text' name='deptname' id='deptname' data-bv-notempty='true' data-bv-notempty-message='deptname 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>deptcode1</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='deptcode1' type='text' name='deptcode1' id='deptcode1' data-bv-notempty='true' data-bv-notempty-message='deptcode1 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>deptname1</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='deptname1' type='text' name='deptname1' id='deptname1' data-bv-notempty='true' data-bv-notempty-message='deptname1 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>cardno</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='cardno' type='text' name='cardno' id='cardno' data-bv-notempty='true' data-bv-notempty-message='cardno 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>cardtype</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='cardtype' type='text' name='cardtype' id='cardtype' data-bv-notempty='true' data-bv-notempty-message='cardtype 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>regdate</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='regdate' type='text' name='regdate' id='regdate' data-bv-notempty='true' data-bv-notempty-message='regdate 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>reghour</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='reghour' type='text' name='reghour' id='reghour' data-bv-notempty='true' data-bv-notempty-message='reghour 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>sign</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='sign' type='text' name='sign' id='sign' data-bv-notempty='true' data-bv-notempty-message='sign 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>cert</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='cert' type='text' name='cert' id='cert' data-bv-notempty='true' data-bv-notempty-message='cert 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>getpersoninfo</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='getpersoninfo' type='text' name='getpersoninfo' id='getpersoninfo' data-bv-notempty='true' data-bv-notempty-message='getpersoninfo 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>trade</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='trade' type='text' name='trade' id='trade' data-bv-notempty='true' data-bv-notempty-message='trade 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>divide</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='divide' type='text' name='divide' id='divide' data-bv-notempty='true' data-bv-notempty-message='divide 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>feetype</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='feetype' type='text' name='feetype' id='feetype' data-bv-notempty='true' data-bv-notempty-message='feetype 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>registerstatus</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='registerstatus' type='text' name='registerstatus' id='registerstatus' data-bv-notempty='true' data-bv-notempty-message='registerstatus 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>feestatus</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='feestatus' type='text' name='feestatus' id='feestatus' data-bv-notempty='true' data-bv-notempty-message='feestatus 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>clinicroom</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='clinicroom' type='text' name='clinicroom' id='clinicroom' data-bv-notempty='true' data-bv-notempty-message='clinicroom 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>receiptsn</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='receiptsn' type='text' name='receiptsn' id='receiptsn' data-bv-notempty='true' data-bv-notempty-message='receiptsn 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>checkopercode</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='checkopercode' type='text' name='checkopercode' id='checkopercode' data-bv-notempty='true' data-bv-notempty-message='checkopercode 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>checkopername</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='checkopername' type='text' name='checkopername' id='checkopername' data-bv-notempty='true' data-bv-notempty-message='checkopername 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>checktime</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='checktime' type='text' name='checktime' id='checktime' data-bv-notempty='true' data-bv-notempty-message='checktime 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>paiduino</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='paiduino' type='text' name='paiduino' id='paiduino' data-bv-notempty='true' data-bv-notempty-message='paiduino 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>dangqianno</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='dangqianno' type='text' name='dangqianno' id='dangqianno' data-bv-notempty='true' data-bv-notempty-message='dangqianno 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>patientname</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='patientname' type='text' name='patientname' id='patientname' data-bv-notempty='true' data-bv-notempty-message='patientname 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>patientphone</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='patientphone' type='text' name='patientphone' id='patientphone' data-bv-notempty='true' data-bv-notempty-message='patientphone 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>patientsocial</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='patientsocial' type='text' name='patientsocial' id='patientsocial' data-bv-notempty='true' data-bv-notempty-message='patientsocial 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>patientid</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='patientid' type='text' name='patientid' id='patientid' data-bv-notempty='true' data-bv-notempty-message='patientid 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>times</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='times' type='text' name='times' id='times' data-bv-notempty='true' data-bv-notempty-message='times 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>hostcode</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='hostcode' type='text' name='hostcode' id='hostcode' data-bv-notempty='true' data-bv-notempty-message='hostcode 不能为空'>
				</div>
			</div>
			<div class='form-group'>
				<label class='col-md-2 control-label'>recordsequence</label>
				<div class='col-md-10'>
					<input class='form-control' placeholder='recordsequence' type='text' name='recordsequence' id='recordsequence' data-bv-notempty='true' data-bv-notempty-message='recordsequence 不能为空'>
				</div>
			</div>


			<div class="form-actions">
				<div class="row" align="center">
					<div class="col-md-12">
					    <button class="btn btn-primary" onclick="location.href='appRegsterPayList.html'">返回</button>
						<button class="btn btn-primary" type="submit" onclick="add()">
							<i class="fa fa-save"></i> 保存
						</button>
					</div>
				</div>
			</div>

		</fieldset>
	</form>
</div>
	<script type="text/javascript" src="../../js/libs/jquery-2.1.1.min.js"></script>
	<script type="text/javascript" src="../../js/jq.js"></script>
	<script type="text/javascript" src="../../js/plugin/bootstrapvalidator/bootstrapValidator.min.js"></script>
	<script type="text/javascript" src="../../js/common.js"></script>
	<script type="text/javascript" src="../../layui/layui.js"></script>
	<script type="text/javascript">
		layui.use(['layer','laydate'], function(){
		    var layer = layui.layer;
		});
		
		function add() {
			$('#form').bootstrapValidator();
			var bootstrapValidator = $("#form").data('bootstrapValidator');
			bootstrapValidator.validate();
		    if(!bootstrapValidator.isValid()){
			   return;
		    }
		    
		    var formdata = $("#form").serializeObject();

			$.ajax({
				type : 'post',
				url : '/appRegsterPays',
				contentType: "application/json; charset=utf-8",  
				data : JSON.stringify(formdata),
				success : function(data) {
					layer.msg("添加成功", {shift: -1, time: 1000}, function(){
                        location.href = "appRegsterPayList.html";
                    });
				}
			});
		}
		
	</script>
</body>
</html>
